Special Tests: Cervical Radiculopathy, Cervicogenic Headache, and Canadian C-spine Rules

Special Tests Covered in this Lesson:

• Wainner's Clinical Prediction Rule for Cervical Radiculopathy
  • Spurling's Compression Test
  • Upper Limb Tension Test
  • Distraction Test
  • Less than 60° of rotation on the affected side
    • Additional Radiculopathy Test
      • Shoulder Abduction Test
• Cervicogenic Headache
  • Cervical Flexion and Rotation Test
• Red Flags
  • Canadian C-spine Rules

Radiculopathy and cervicogenic headache are relatively common symptom clusters correlated with chronic and acute cervical spine dysfunction. For example, long hours behind a desk with forward head postures, and whiplash syndrome following a car accident, can result in symptoms that match these diagnoses. Often patient complaints include the feeling of a "pinched nerve" with lateral bending (lateral flexion) or axial compression. Or, they may mention that their headache and neck symptoms tend to get worse at the same time, and sometimes "massage" aids in reducing their symptoms. In more serious cases nerve root compression (for example, with herniated disk) can result in radicular symptoms and muscle weakness. Both cervical radiculopathy and cervicogenic headache can be reliability assessed using the special tests covered in this course. For more serious issues that may imply a need for emergency care, the Canadian C-spine rules have demonstrated high sensitivity and utility in clinical practice. For example, fear of moving the neck and significant muscle weakness should imply a recommendation to visit an emergency room.

Summary:

The special tests that demonstrate an acceptable level of accuracy for the cervical spine focus on just a few diagnoses, and likely miss the most common cervical complaints. Radiculopathy, cervicogenic headache, and screening for necessary imaging are covered in this course. These diagnoses do not include the common complaints of mechanical/postural chronic neck pain. Clinical experience and a comprehensive subjective examination will likely dictate whether the testing below is necessary. The most accurate tests, based on available research, were chosen for each potential diagnosis.

• Cervical Radiculopathy: Generally, cervical radiculopathy tests are more specific than sensitive. For example, the Wainner's Clinical Prediction Rule (CPR), a cluster of radiculopathy tests, demonstrates very high specificity but low sensitivity (12). This is a little odd considering this CPR includes the Upper Limb Tension Tests (ULTTs) which have high sensitivity. Alternatively, the ULTTs exhibit relatively high sensitivity and low specificity (4, 6, 12, 15, 16 - 19), which may imply they are a useful screen for diagnoses such as "nerve pain", "radicular symptoms", or "nerve root irritation". Note, Wainner's CPR is more accurate than the use of axial compression, distraction, or lateral bending tests alone.
• Cervicogenic Headache: Cervicogenic headache is a diagnosis that licensed human movement professionals should give more attention to. The prevalence of cervicogenic headache is relatively common; however, it seems these patients are not referred to licensed human movement professionals often. There is one particular test that demonstrates high sensitivity and specificity for this diagnosis (21 - 25).
• Red Flags: Canadian C-spine Rules are important for identifying "red flag" conditions (spinal cord injury, emergent need for spine surgery, muscle weakness (neurological motor loss, etc.) that should be referred out for imaging and additional diagnostics before intervention is attempted. These rules are highly-sensitive, which is ideal for a screen of this type (26 - 30)

Brookbush Institute Recommendation:

• The Brookbush Institute recommends that all clinical professionals are aware of these special tests (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.). The Wainner's Clinical Prediction Rule for Cervical Radiculopathy , and the Cervical Flexion and Rotation Test for cervicogenic headache, are particularly effective for identifying two diagnoses that may be best treated by movement professionals. Additionally, a copy of the Canadian C-spine Rules should be easily accessible for identifying cervical patients with "red flags" who should be referred out for additional testing.

For an Introduction to Special Tests:

• For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:
• Special Tests: Introduction

Additional Special Tests for the Cervical Spine:

• Special Tests: Upper Cervical Spine Instability and Vertebrobasilar Insufficiency (VBI)